This is not the official
website for HealthCare.Gov, but as a Certified Agent with FFM
HealthCare.gov I can answer your questions. Please visit
http://www.healthcare.gov for complete information and
Serving Clients in the
following Counties and Cities. This is not a complete list, as
we help all clients in Oregon
Starting November 15th, 2014 I will
have access to help enroll clients through the HealthCare.Gov
Portal. As a Certified Agent I can answer questions, and show
you the plan options and rates which will go effective January 1st,
2015. If you would like my help just click the above link and I
will give you a call and answer questions you have. My time and
services are free and I am available 9:00 am to 8:00 pm 7 days a
Between Jobs, or Unemployed!
Offered Cobra Health Insurance and cannot afford the premiums? The
are many Low Cost, and Affordable options. All coverage is with
Major Health Insurance Companies and a "Real Person" will answer the
phone to help you!
The focus of this website is to
provide consumers a simple, and professional environment when
looking for Affordable, and Low Cost Health Insurance. Licensed
Health Insurance Agents are available and will take the time to
answer all your questions, and help find the Health Plan that best
meets your needs
Health Insurance Benefits are
always changing, and health insurance companies are providing more
options that benefit the consumer. Alternative, or Holistic health
care is now offered through many of the health insurance companies.
You can now see your Naturopathic Physician, and be covered under
the doctor office co-pay, and have unlimited visits. Chiropractic,
and Acupuncture are also included as standard health care benefits
with many companies.
If you are looking for Low Cost and
Affordable Dental and Vision benefits included within the health
plan, we can help you select the Health Insurance Company that will
meet your needs.
Health Benefit Solution, Inc is
licensed through the Oregon Insurance Division, and has contracted
with most all the major health insurance companies to provide the
consumer with choice and options when looking for the plan that
meets the life style and needs of the insured.
Health Benefits Solution, Inc is a leader in offering Company
Direct Health insurance coverage for all individuals, and small
business in Oregon. The Affordable Care Act and
HealthCare.gov will offer affordable health insurance
options to all Oregonians with or without tax credits or CSR "Cost
Sharing Reductions". The Oregon Health Plan will still be
Qualifying employers can take advantage of the IRS Small
Business Health Care Tax Credit, even
though Cover Oregon cannot yet serve small businesses. Cover
Oregon and participating insurance
companies worked together to make this possible.
Beginning April 1, 2014, when an employer purchases or renews
a Cover Oregon-certified medical
or dental plan directly from a participating insurance
company, Cover Oregon will confirm their
eligibility to shop within Cover Oregon and provide an
Eligibility Notice. An employer may be
eligible for the small business tax credit if all of the
following criteria are met:
• Employ fewer than 25 full-time equivalent employees (FTEs);
• Pay average annual wages of less than $50,000 per
full-time-equivalent employee per year;
• Pay at least 50% of the premium cost of qualified
employee-only health insurance coverage for
• Purchase in one or more Cover Oregon-certified medical
and/or dental plans directly with an
Steps to apply for the Small Business Health Care Tax Credit
*Cover Oregon does not determine eligibility for the Small
Business Tax Credit.
Consult your tax professional for more information or visit
irs.gov and select “Credits & Deductions”.
Oregon health insurance exchange
Cover Oregon successfully
transitioning to Healthcare.gov partnership
Following months of efforts to fix the troubled
website, Cover Oregon’s board voted on April 25 to
switch to using Healthcare.gov rather than continue to
try to repair the existing site. The Cover Oregon website
will still exist, but will redirect visitors to
The supported state based marketplace (SSBM) model
means that Cover Oregon will be working together with HHS,
with the state retaining some functions and HealthCare.gov
being utilized to enroll people in private plans through
the exchange. Tina Edlund, Director of the Oregon Health
Agency, was selected in
early May to lead the transition.
At a board meeting on October 9, Cover Oregon provided
detailed update on the exchange’s transition to
HealthCare.gov – which appears to be going very well more
than a month ahead of open enrollment. All 15 carriers
offering plans in the exchange have been added to the
HealthCare.gov system, and testing between the carriers
and HealthCare.gov began on October 9.
Cover Oregon is working together with CMS to create
“learning pages” that will be hosted on HealthCare.gov and
will help prepare Oregon residents for the upcoming open
The exchange will be utilizing
three separate websites during open enrollment, but
they will be interoperable. HealthCare.gov will be the
main enrollment platform for people applying for private
plans and for income-based Medicaid. CoverOregon.com will
be available to help people find local in-person
assistance with enrollment. In addition,
OregonHealthcare.gov will help applicants who are eligible
for Medicaid for reasons other than income (disability,
Enrolling and re-enrolling for 2015
All 2014 policies that were purchased through Cover
Oregon will terminate on December 31, 2014. Open
enrollment begins on November 15 and ends on February 15.
But in order to have seamless coverage, with a new plan
taking effect January 1, current enrollees must
re-enroll through HealthCare.gov between November
15 and December 15.
In addition to the existing policy-holders who will
need to re-enroll, new applicants will also be able to
obtain coverage during open enrollment. To have a policy
in place on January 1, the enrollment must be completed by
Oregon has completed the rate review process for 2015.
So although enrollment and 2015 rates will not be
available on Healthcare.gov until November 15, Oregon
residents can visit
oregonhealthrates.org to see detailed information
about the rate review process and the average rates for
Although Healthcare.gov will be handling Oregon’s
private plan enrollments for 2015, Cover Oregon will still
be involved in Oregon Health Plan Medicaid enrollment.
The exchange confirmed in mid-August that the online
application for Oregon Health Plan will be more
streamlined and the eligibility determination process will
be completely automated by 2015. But there are still some
doubts as to whether the entire process for seamless
Medicaid enrollment will be up and running by November.
2014 progress despite challenges
Although the Cover Oregon website has been largely
regarded as a technological disaster,
things should be much better during the 2015 open
enrollment period, when enrollments will be processed
through Healthcare.gov. Despite myriad technological
problems, Cover Oregon had still enrolled just over
100,000 people in private plans by August 25 (only
about 79,000 of those policies are still active, the rest
either didn’t pay their premiums or have cancelled their
coverage at some point during the year; significant
attrition is always expected in the individual insurance
market). Of the private plan enrollees, roughly
53 percent were uninsured prior to obtaining a policy
through Cover Oregon.
Oregon expanded Medicaid under the ACA, and 330,000
people had enrolled in Medicaid by June (Oregon Health
Plan), the majority of them completing their Medicaid
enrollment via Cover Oregon. From June 2013 to June 2014,
Medicaid enrollment in Oregon increased by
58 percent – from about 614,000 people to about
Despite the tremendous technological difficulties
experienced by the exchange, Oregon had the
seventh highest drop in uninsured rate during the
first half of 2014 according to a recent Gallup poll. The
state’s uninsured rate was 19.4 percent in 2013, and had
fallen to 14 percent by mid-2014.
Turning around a failed exchange
Cover Oregon will be switching to a SSBM by the start
of the 2015 open enrollment period, but the exchange is
still working to repair itself. In mid-June, Cover Oregon
announced that they had selected a new executive
director, Aaron Patnode. The hiring of Patnode, who was
previously a Kaiser Permanente manager, indicates that the
exchange is still thinking long-term, and Patnode’s
reputation as a problem solver and “turn-around artist”
bodes well for the long-term success of the exchange in a
partnership with HHS, or possibly as a fully state-run
marketplace in 2016 or beyond.
In addition to Patnode, the state also hired “corporate
turnaround expert” Clyde Hamstreet earlier this year in an
effort to right the failed exchange. Hamstreet and two
assistants worked throughout the summer and the exchange
upwards of $600,000 on their services so far.
Uncovering what went wrong
federal prosecutors have launched investigations into
the failed exchange – which cost $248 million in tax
dollars and was never able to enroll applicants entirely
online. In early June, Governor John Kitzhaber asked
Oregon Attorney General Ellen Rosenblum to
take legal action against Oracle – the creator of the
Cover Oregon website – in order to recover funds spent on
But Oracle is fighting back, saying that officials at
Cover Oregon and Oregon Health Authority are to blame for
the debacle. Both sides have
sued each other, and the issue was still highly
contentious by late August.
On February 18, four and a half months after open
enrollment began, Cover Oregon’s website was finally
functional enough for insurance agents and navigators
to be able to process enrollments start to finish online.
Although the site was never fully functional for the
general public to complete the entire enrollment process
online, the availability of some electronic enrollment was
a huge improvement after months of relying solely on paper
Despite the fact that Cover Oregon was the only
exchange relying solely on paper applications for the
first four months of open enrollment, its total enrollment
numbers are around the middle of the road when compared
with enrollment in other states – all of which were using
much more efficient online applications for months.
Grandmothered plans can be renewed
Virtually all of the existing 2013 individual policies
in Oregon were eligible for renewal into 2014. Moda
Health Plan Inc. and PacificSource Health Plans allowed
existing policies to extend until the end of March. And
seven carriers allowed 2013 policies to be renewed until
the end of 2014: Regence BlueCross BlueShield of Oregon,
Kaiser Foundation Health Plan of the Northwest, Providence
Health Plan, LifeWise Health Plan of Oregon, Health Net
Health Plan of Oregon Inc., Time Insurance Co. and John
Alden Life Insurance Co.
The renewal of 2013 plans into 2014 gave many Oregon
residents in the individual market some breathing room as
they waited for Cover Oregon’s website to improve.
Oregon is also
permitting those pre-2014 plans to be renewed again
this fall and remain in force throughout 2015, at each
Exchange worked to cover risk pool members
The Oregon Medical Insurance Pool – a state run high
risk pool – closed at the end of December, but the state
temporary medical insurance program that automatically
covered risk pool members who were not able to enroll in
an exchange plan with a January 1 effective date.
The temporary plan remained in force until March 31,
ceased operation at that point. Insureds who were
still covered under the temporary program lost their
coverage at the end of March, but the risk pool had been
working closely with members to get them transitioned to
new policies, so there were very few people still on the
temporary program at that point.
Cover Oregon’s history
The Oregon legislature authorized a state-run health
insurance exchange in 2011, and the exchange developed a
formal business plan, which the Legislature approved in
February 2012 as a final go-ahead for the exchange. The
U.S. Department of Health and Human Services (HHS) gave
conditional approval to Cover Oregon in December 2012. The
exchange has a 2014 budget of $105.7 million, which will
be covered with federal grant money, and $62.4 million
budget in 2015 according to a Cover Oregon spokesperson.
Cover Oregon is overseen by a nine-member board of
directors, two of which are non-voting members. The board
receives input from the Individual and Employer Consumer
Advisory Committee. The 19-member committee holds monthly
meetings, which are open to the public. The Consumer
Advisory Committee was mandated by the legislation that
established the state’s exchange.
Committee members are selected by the board and must
include individuals or employers who will use the
exchange, individuals who will enroll in state medical
assistance through the exchange, minority groups, and
representatives of organizations that will people purchase
insurance through the exchange. All geographic areas of
the state must be represented.
Cover Oregon is acting as “active purchaser,” meaning
it limits the number of health insurers that can
participate in the exchange. Participating insurers are
required to offer a bronze, silver and gold plan and have
the option to offer additional plans.
If you like your plan you can keep it.
Under ObamaCare you can keep your health insurance until
2015, even if it doesn't comply with the ACA. Come 2015, if
your plan doesn't have a
grandfathered status and doesn't meet
requirements of the ACA, then you will
have to choose a new plan. Let's look a little deeper into
the details you need to know about keeping your plan.
SPECIAL UPDATE: You can now keep your plan until
2017 in some states!
The Department of Health and Human Services (HHS, i.e.
the department in charge of ObamaCare) has announced that
health insurance plans that were supposed to be canceled by
Obamacare by 2014 may be sold through October of 2016 in
states that approve of the extension. This essentially
extends some non-compliant non-grandfathered plans until
2017 (a plan renewed in 2016 is good for one year, the
latest date to renew your plan is October 2016).
Americans Can Now Keep Their Plans
The Affordable Care Act contains provisions that state
that health plans that don't have a grandfathered status and
don't comply with the ACA need to be changed by 2014. After
a lot of controversy and millions of Americans facing losing
their health insurance for 2014, the President announced a
fix that allows for insurance companies to reinstate health
plans that were canceled until 2015 and has allowed
insurance companies to renew other non-compliant health
plans until 2015 as well.
However, insurance companies must tell policy holders
that their plans do not meet the new minimum standards and
must inform them about other options on the new
marketplaces, including the availability of subsidies to
help them pay their insurance costs.
This move will allow Americans to shop around on the
exchanges and see if their is a better option for them and
their family while still allowing them to keep their current
health plan, regardless of if it meets the new standards of
the Affordable Care Act.
All new plans sold in 2014 still have
to comply with the ACA.
Can I Keep My Current Health Plan
Private health plans, including employer group health
plans, that don't meet the standards of the Affordable Care
Act and don't have a grandfathered status may have to be
switched to health plans that do. You can keep your current
health plan after 2015 if:
• Some States with working health insurance marketplaces,
like Washington State, have rejected the "fix" to let people
to keep health insurance plans that would be canceled under
the Affordable Care Act . Your insurance company will be
able to confirm whether you can keep your plan, or buy a
non-compliant plan in your State.
• Your private plan has grandfathered status and remains
unchanged by the provider.
• You have a non-grandfathered private plan that meets
the requirements of the Affordable Care Act (listed below).
• You have Medicare, Medicaid, TRICARE or another form of
Public health care.
You may have to switch to a new health plan if:
• Your plan doesn't have, or loses, grandfathered status
and doesn't meet the requirements of the ACA.
Everyone is required to have insurance for 2014, allowing
some to keep their plans and others to buy new plans with
more coverage will unbalance the cost of premiums. It
creates two separate pools of healthy and sick people.
The healthy people would be more likely to stick with the
old plans, which cost less and offer less coverage because
they don’t expect to need it. Meanwhile, sick people would
buy the more expensive, comprehensive plans.
The point of discontinuing plans that didn't provide
adequate coverage was to ensure that if everyone had to have
coverage then they would all have to be part of the same
risk pool, ensuring that prices were at their most
affordable for everyone.
Below are some of the benefits of new insurance plans
that plans that face or will face cancellation don't have to
The Truth Behind, "If You Like
Your Plan You Can Keep it"
A common talking point of supporters of the Affordable
Care Act was, "if you like your plan you can keep it." Like
many other talking points this is only a half truth.
The quote should be, "If you have a non-grandfathered plan
that meets the requirements of the ACA, you can keep it.
Also if you have a grandfathered health plan that doesn't
meet the requirements of the ACA you can keep it as long as
the benefits remain relativity unchanged. However, most
grandfathered plans will change and will require people on
those plans to move to a new plan that does meet the
requirements of the ACA."
In order for a plan to be in danger of cancellation it is
most likely not offering at least one of these new mandatory
benefits, rights, and protections:
1. A Ban on denied treatment or coverage for
preexisting conditions. You can't be denied or
dropped from coverage for being sick.
2. Ten Essential Health Benefits.
Essential Health Benefits have no annual or lifetime dollar
3. A Ban on rescission of health insurance
coverage and the right to an appeal. You can't be
dropped for any reason other than fraud and if you are
dropped you have the right to a quick internal and external
4. Ban on Discrimination based on gender or
health. You can no longer be charged more for being
5. Ban on all lifetime limits and $2,000,000 Cap
on annual limits. You are more protected from
bankruptcy due to costly medical expenses.
6. Free Preventive Services and Wellness Visits.
Can I Keep My Current
If your plan doesn't meet the standards of the Affordable
Care Act and it's not protected by its grandfathered status
then your insurance company will either issue you a new plan
or cancel your current plan and let you know other plan
options available to you. In some cases your insurer will
notify you by mail, in other cases they will provide more
assistance. While this can be a pain, the new plan you get
will offer the new benefits, rights, and protections
guaranteed by the Affordable Care Act.
Will a New Plan Cost Me More?
In some cases new plans will have better protections for
a higher cost and in some cases families will get a cheaper
plan with better benefits. The important thing to realize is
that no matter how good your premium prices, cost sharing,
or network was on your old plan it didn't have the same
rights and protections of newer plans. Also note that if you
make under 400% of the Federal Poverty Level in 2014 you
will have access to cost assistance through the health
insurance marketplace. In most cases you can find an
equivalent plan to what you have now through your current
insurer or the marketplace.
The Dangers of Keeping an Old
Health Care Plan
Please be aware that health insurance plans are being
dropped for a reason in many cases. Some older plans don't
offer reasonable coverage, or can drop you when you get
sick, or deny you treatment when you need it most. Annual
and lifetime limits on your care can led to bankruptcy and
many plans can currently charge women significantly more
than men. Make sure you understand what rights and
protections your plan offers.
Also make sure that you check out your State's health
insurance marketplace and see if you qualify for cost
The Benefits Of Keeping Your Old
Health Care Plan
For some Americans they will want to keep their old
health insurance policy as long as possible. If your plan
has a grandfathered status you are safe, if it doesn't
you'll be able to keep it until 2015. Older grandfathered
plans don't have to comply with the new law and for some
this means they will be able to get lower rates and also get
the care they need. See our page on grandfathered health
plans for more "benefits
of grandfathered plans".
At the end of the day we suggest that everyone take 2014
to apply for their State's health insurance marketplace and
to see what their options are. This way when 2015 rolls
around there will be far less confusion as to what your
health insurance options are. Learn more aboutGrandfathered Health Plans (the plans
you CAN keep) and the
Health Insurance Marketplace (where you
go to get a new plan that complies with the ACA).
People who enrolled in Oregon's troubled health
insurance exchange will have to re-enroll for coverage, as Cover
Oregon transitions to the federal government.
Tina Edlund of the Cover Oregon Transition
Project told the Oregon Health Policy Board this week that come
November, about 80,000 Oregonians will have to log on to
healthcare.gov to get their insurance.
"No matter what, people were going to have to go
back. Even if they'd just stayed with Cover Oregon, they were going
to have to go back and update information," Edlund said.
"You know, changes in your family, changes in
your income. All of that and just like all of us have to go with our
employer sponsored insurance and make up dates on an annual basis.
Some of this was going to have to happen anyway."
months of trying to get its problem-plagued online health
exchange to work, Oregon on Friday officially gave up on the
state portal and decided to switch to the federal website - the
first state in the nation to do so.
Cover Oregon's board
approved an advisory committee's recommendation to ditch its
troubled portal. Oregon will use HealthCare.Gov for private
Officials say fixing the
existing system would be too costly at $78 million and would
take too long. Switching to the federal system would cost just
$4 million to $6 million.
Oregon's exchange is seen
as the worst in more than a dozen states that developed their
own online health insurance marketplaces. The general public
still can't use Cover Oregon's website to sign up for coverage
in one sitting.
Instead, Oregonians must
use a time-consuming hybrid paper-online process to sign up for
insurance - despite $134 million the state paid Oracle Corp. to
build the online exchange. Oregon
received a monthlong enrollment-deadline extension because
of the technology problems.
Several other states
experienced major problems with their exchanges, but only one
has chosen to replace its site. Maryland recently decided to
adopt the technology used on Connecticut's successful exchange.
Federal officials said
the federal exchange is able to add more states, and they are
working with Oregon on the next steps.
In March, the federal
Government Accountability Office announced an investigation of
Oregon's exchange, including looking at whether the federal
government can reclaim grant money given to Cover Oregon if
taxpayer funds were mismanaged.
Separately, former Health
and Human Services Secretary Kathleen Sebelius asked for an
inspector general's probe into problems with the rollout of the
health care law.
investigation ordered by Gov. John Kitzhaber found state
managers repeatedly failed to heed reports about technical
problems that prevented the Cover Oregon exchange from
launching. It also found Oracle did a shoddy job in building the
exchange. Five Oregon officials connected to the development of
the Cover Oregon portal have resigned.
Kitzhaber has insisted
communications about the portal's troubles never reached him as
the planned Oct. 1 launch neared. The governor said he agreed
with the technology advisory committee's recommendation.
Officials said they will
keep the Cover Oregon website, but it will be redesigned to
direct people to the federal site. Oregon also will use the
federal call center, but it will retain some front-end customer
outreach, education efforts and initial carrier management.
enrolls people only in private health plans, Oregonians found
eligible for Medicaid will be redirected to the Oregon Health
Authority, a state agency that can enroll them in the Oregon
Health Plan, Oregon's version of Medicaid.
So far, about 242,000
Oregonians have enrolled in coverage through Cover Oregon. About
70,000 of those enrolled in private health plans, while 172,000
enrolled in the Oregon Health Plan.
The health care law gives
middle class families the security of affordable coverage
they deserve and protects every American from the worst
insurance company abuses.
Ended insurance companies'
unchecked power to cancel policies, deny coverage, or
charge women more than men, and established new rights
to appeal insurance company decisions.
While the intent was to allow registration and selection
of coverage via a website, the site has been plagued with
problems and it was only possible to purchase insurance via
As of January 2014, almost $200 million of the $300 million
allocated to develop and operate the Cover Oregon website
had been spent.
As a result of the ongoing problems, in April 2014, the
board of directors voted to close the state-run exchange and
adopt the Federal
HealthCare.gov exchange beginning in 2015.
Health insurance exchanges were established as a part of
Patient Protection and Affordable Care Act to enable
individuals to purchase health insurance in state-run
In this legislation, states could choose to establish their
own health insurance exchanges; if they choose not to do so,
the federal government would run one for the state.
In 2011, the
Oregon Legislative Assembly passed Senate Bill 99,
establishing Oregon's own exchange.
Rocky King was named executive director of the exchange in
and on October 1, 2012, the exchange was named Cover
Development of the website that would process online
enrollments was done by
Oracle Corporation and managed by the state of Oregon
rather than an independent systems integrator.
The project was plagued by numerous management and
technological issues, and though the website was supposed to
begin processing enrollments on October 1, by mid-October,
it was unable to process any enrollments.
As of mid-December 2013, the deadline for enrollment for
coverage beginning January 1, the state had spent nearly
$160 million and the site still could not process online
John Kitzhaber informed Oregon residents that they
should obtain a paper application and mail it in to obtain
coverage. The state hired or reassigned nearly 500 people to
process paper applications.
As of April 2014, the website was still not accepting
online enrollments. 200,000 people had enrolled in Cover
Oregon via paper applications, the majority through the
Oregon Health Plan (Oregon's implementation of
Cover Oregon Executive Director Rocky King and
Oregon Health Authority chief information officer
Carolyn Lawson both resigned in the wake of the failure of
Interim executive director Bruce Goldberg stepped down in
April 2014 and was replaced by Clyde Hamstreet, a consultant
who specializes in corporate turnarounds.
Faced with millions to make Cover Oregon functional, the
board of directors voted in April 2014 to scrap the website
in favor of adopting the Federal
HealthCare.gov website for 2015 enrollments.
Existing subscribers will have to re-enroll with the Federal
In August 2014, Oracle Corporation sued Cover Oregon for
breach of contract,
and then later that month the state of Oregon sued Oracle
Corporation, in a civil complaint for breach of contract and
In 2014, 11 insurers offer plans on the individual/family
market through Cover Oregon.
Most health plans must cover a set of preventive services like shots
and screening tests at no cost to you. This includes Marketplace
private insurance plans.
Free preventive services
All Marketplace plans and many other plans must cover the following
list of preventive services without charging you acopaymentorcoinsurance.
This is true even if you haven’t met your yearlydeductible.
This applies only when these services are delivered by a network
Ambulatory patient services (Outpatient care).Care
you receive without being admitted to a hospital, such as at a
doctor’s office, clinic or same-day (“outpatient”) surgery center.
Also included in this category are home health services and
hospice care (note: some plans may limit coverage to no more than
Emergency Services (Trips to the emergency room).Care
you receive for conditions that could lead to serious disability
or death if not immediately treated, such as accidents or sudden
illness. Typically, this is a trip to the emergency room, and
includes transport by ambulance. You cannot be penalized for going
out-of-network or for not having prior authorization.
Hospitalization (Treatment in the hospital for
you receive as a hospital patient, including care from doctors,
nurses and other hospital staff, laboratory and other tests,
medications you receive during your hospital stay, and room and
board. Hospitalization coverage also includes surgeries,
transplants and care received in a skilled nursing facility, such
as a nursing home that specializes in the care of the elderly
(note: some plans may limit skilled nursing facility coverage to
no more than 45 days).
Maternity and newborn care.Care
that women receive during pregnancy (prenatal care), throughout
labor, delivery and post-delivery, and care for newborn babies.
Mental health services and addiction treatment.
Inpatient and outpatient care provided to evaluate, diagnose and
treat a mental health condition or substance abuse disorder . This
includes behavioral health treatment, counseling, and
psychotherapy. (note: some plans may limit coverage to 20 days
each year. Limits must comply with state or federal parity laws.
that are prescribed by a doctor to treat an illness or condition.
Examples include prescription antibiotics to treat an infection or
medication used to treat an ongoing condition, such as high
cholesterol. At least one prescription drug must be covered for
each category and classification of federally approved drugs,
however limitations do apply. Some prescription drugs can be
excluded. "Over the counter" drugs are usually not covered even if
a doctor writes you a prescription for them. Insurers may limit
drugs they will cover, covering only generic versions of drugs
where generics are available. Some medicines are excluded where a
cheaper equally effective medicine is available, or the insurer
may impose "Step" requirements (expensive drugs can only be
prescribed if doctor has tried a cheaper alternative and found
that it was not effective). Some expensive drugs will need special
Rehabilitative services and devices –
Rehabilitative services (help recovering skills, like speech
therapy after a stroke) andhabilitativeservices
(help developing skills, like speech therapy for children) and
devices to help you gain or recover mental and physical skills
lost to injury, disability or a chronic condition (this also
includes devices needed for "habilitative reasons"). Plans have to
provide 30 visits each year for either physical or occupational
therapy, or visits to the chiropractor. Plans must also cover 30
visits for speech therapy as well as 30 visits for cardiac or
provided to help a doctor diagnose an injury, illness or
condition, or to monitor the effectiveness of a particular
treatment. Some preventive screenings, such as breast cancer
screenings and prostrate exams, are provided free of charge.
Preventive services, wellness services, and chronic
includes counseling, preventive care, such as physicals,
immunizations and screenings, like cancer screenings, designed to
prevent or detect certain medical conditions. Also, care for
chronic conditions, such as asthma and diabetes. (note: please see
our full list ofPreventive
services for details on which services are covered.)
provided to infants and children, including well-child visits and
recommended vaccines and immunizations. Dental and vision care
must be offered to children younger than 19. This includes two
routine dental exams, an eye exam and corrective lenses each year.
While all qualified plans must offer the ten essential benefits, the
scope and quantity of services offered under each category can vary.
Each qualified plan must offer essential health benefits which
overall are equal to the scope of benefits typically covered by
employers, as shown by a Department of Labor survey of
employer-sponsored coverage. (Ref:ACA,
Section 1302 (b) (2) (a))
Under theAffordable Care
are offered on all qualifying plans starting January 1st, 2014.
Who Has Access to Essential Health Benefits?
All plans sold in individual and small group markets, including
plans sold on and off the Health Insurance Marketplace, and
Government healthcare plans like Medicaid andMedicareall
include at least 10 Essential Benefits. Grandfathered plans from
before the law was enacted in March 23, 2010, plans that will be
discontinued in 2015 (2014 in some States), self-funded ASO (administrative
services organization) plans, and large group plans
don't have to offer Essential Benefits.
• In older plans, not offering these benefits can translate to lower
premium costs (because they offer less benefits)
• Large group plans almost all already offer essential health
benefits or their equivalent.
• All new Medicaid and Medicare plans must offer essential health
benefits starting in 2014.
• Specific health care benefits may vary by state. Even within the
same state, there can be small differences between health insurance
What Do Essential Benefits Cost?
Some Essential Benefits include no out-of-pocket costs (no cost
sharing) and all Essential Benefits offer no annual or lifetime
limits and have minimum cost sharing limits.
No Cost Sharing on Some Preventive Services
Essential Health Benefits include annual wellness visits and many
types of preventive services including immunizations and screenings
at no out of pocket costs. The Affordable Care Act has a major focus
on wellness and prevention to help increase early detection and
catch sickness before it starts increasing wellness and decreasing
the need for costly treatments. (note: For preventive care to have
no out-of-pocket expense it must be delivered by a network
No Annual Limits on Essential Health Benefits
There are no dollar limits on Essential Benefits. Before annual and
lifetime limits over 60% of bankruptcies in the US were medical
bankruptcies. Eliminating dollar limits on essential care ensures
that patients won't have to stop treatment and/or go broke when they
reach their dollar limit.
A Minimum Actuarial Value on All Coverage
There is a cap on out-of-pocket costs on all plans that cover
Essential Benefits. Plans offering Essential Benefits must cover at
least 60% of covered out-of-pocket expenses and must have reasonable
out-of-pocket maximums (in other words a plan offering essential
benefits must be at least the equivalent to a "bronze" plan sold on
Plans must provide one of four levels of benefits, named "Bronze",
"Silver", "Gold" and Platinum. Each designation represents an
"actuarial value", which is calculated as the average % of total
health costs they cover for a defined population). Bronze plans
cover 60% on average, "Silver" 70%, "Gold" 80% and "Platinum" 90% of
costs on average. For most individuals though a plan will pay far
less than these percentages: this is because a high proportion of
health care costs are incurred by a small number of very sick
people, and once they reach the out-of-pocket maximums, the plan
pays 100% of their extra costs.
In general, the higher the metallic level (i.e. Gold and Platinum),
the more the plan will pay towards your healthcare expenses, but the
higher your monthly premiums will be. Higher tier plans may also
offer additional benefits that are not considered "essential".
Out-of-pocket Maximum (Limit)
Your out-of-pocket maximum (limit) is the most you pay during a
policy period (usually a year) before your health insurance or plan
begins to pay 100% of the allowed amount. This limit never includes
your premium, balance-billed charges, or health care your health
insurance or plan doesn’t cover. All cost sharing for Essential
Benefits counts towards your out-of-pocket limit.
Please note that some plans don’t count your copayments,
deductibles, coinsurance payments, out-of-network payments, or other
expenses toward this limit. In Medicaid and CHIP, the limit includes
premiums. The maximum out-of-pocket costs for any Marketplace plan
for 2014 are $6,350 for an individual plan and $12,700 for a family
Why Do I Need Essential Health Benefits?
In the past many plans offered sub-par coverage as a way to keep
premium costs down. This would seem attractive until one actually
needed care. This led to many cases of Americans paying for plans
for years and then finding that they did not have access to the care
they needed or hit a dollar limit and were denied treatment when
they needed it most. Today all plans cover essential health benefits
to ensure that we all get the care we need.
Why Do I Have to Pay For Benefits I Don't Need?
While most Essential benefits could be used by anyone, many benefits
like Maternity services are included on all plans. One could argue a
single male, who never has children, won't benefit from this
directly (although it's easy to argue countless ways he benefits
indirectly notably his mother, sisters, relatives, community, etc),
leading to the obvious question, "why do I have to pay for something
I don't need?"
In employment based group health insurance policies, all employees
of a company pay the same premium, regardless of their individual
health needs. So the premium younger workers pay helps subsidize the
higher health costs of older employees. Although this means higher
premiums for young employees, when employees get older they will
benefit from this arrangement. Similarly male workers will pay
premiums that include costs of maternity care and breast cancer,
even though they are unlikely to need either. In insurance terms,
all members of the group are considered as a "risk pool".
The Affordable Care Act creates a "single risk pool" in the
individual and small group markets that mirrors the "risk pools"
employees of large firms have enjoyed in the past. This means that
regardless of what care you need, or may need, we all share the cost
and the risk. This allows insurance companies to cover men at the
same rate as women and sick people at the same rate as healthy
people. Without a single risk pool insurance would still be
unaffordable for many and preexisting conditions would not be
covered. Since there is a single risk pool that splits the costs of
Essential Benefits all Essential Benefits are offered to all
How Do I Know if My Plan Covers Essential Health Benefits?
If you enrolled in an individual or small group plan after 2014 you
most likely have access to Essential Health Benefits that follow the
rules of the ACA. The same is true for Medicare and Medicaid.
The ACA contains exceptions for "grandfathered" plans, . These are
plans that existed prior to the Act - March 23, 2010, provided that
they have not changed significantly. Unfortunately most insurance
plans change "significantly" almost every year, so few plans are "grandfathered".There
are also special exceptions for self-insured groups, andstudent
health plans. In addition both large employer group
plans, and now individual plans, have been allowed to continue until
Exceptions and Limits on Essential Health Benefits
There are some exceptions and limits on Essential Benefits, they
• Insurance companies can still put a yearly dollar limit and a
lifetime dollar limit on spending for health care services that are
not considered essential health benefits.
• Some health insurance plans may have received a temporary waiver
from the rules on yearly dollar limits. Yearly limit waivers end
with plan or policy years beginning in 2015 (2014 in some States).
• All non-grandfathered health plan must limit the total
out-of-pocket costs enrollees pay for in-network.
• Health plans can still however set limits on the number of times
you can receive a certain treatment.
• Large Group markets and self funded (ASOs) don't need to offer
Essential Benefits Facts
Here are some quick facts about Essential Health Benefits and the
Affordable Care Act (ObamaCare):
• Cost sharing on Essential Health Benefits count towards your
• Aside from the Essential Health Benefits, plans may offer a number
of additional benefits.
• Some plans may offer better cost sharing options on benefits
subject to out-of-pocket cost sharing. In general the more
"valuable" the metal, the higher the percentage of out-of-pocket
costs covered by your insurer.
• Essential Health Benefits include the most commonly used health
services like preventive services and annual wellness visits with no
• Essential Health Benefits include preventions and treatments you
need if you get sick. This includes ongoing treatment for common
serious sicknesses like cancer.
• There are no annual or lifetime limits on Essential Health
Benefits. Before the ACA over 60% of all bankruptcies in the US were
medical related, many due to the cost of treatment exceeding annual
and lifetime dollar limits.
• The annual cost to society of substance use disorders alone is
approximately $200 billion, yet only a fraction ($15 billion) is
spent on treatment. The inclusion of mental health and substance use
disorders services is projected to balance these numbers and reduce
Here are some common myths about Essential Health Benefits and the
Affordable Care Act (ObamaCare):
•There are no
dollar limits on healthcare.Dollar
limits still apply to non-essential treatments, essential benefits
are covered at no dollar limits and must have reasonable
Benefits are "free".Only
some preventive services have no out-of-pocket expenses. Other
benefits may have reduced, or no, out-of-pocket expenses depending
on the plan. Even a "free" service still comes with the cost of your
monthly premium. See a list of all required "free"Preventive
• Abortions have to be provided on demand at public cost.False!
The ACA Sect 1303 explicitly prohibits abortion from coverage as an
"essential benefit" and confirms existing Federal and State
prohibitions on use of public funds for abortion services. Insurers
may voluntarily decide to include abortions in their plans: some
plans only cover abortion services only in cases of life
endangerment, rape, and incest. States who are providing their own
health insurance marketplaces, prohibit coverage of abortion
services. So far Arizona, Louisiana, Mississippi, Missouri, and
Tennessee have banned coverage of abortions. The bans in Louisiana
and Tennessee do not contain any exceptions. Missouri only allows
coverage where a woman’s life is endangered, Arizona has a life and
narrow health exception,and Mississippi allows coverage where a
woman’s life is endangered or the pregnancy is the result of rape or
incest. In addition – Idaho, Oklahoma, Kentucky, Missouri and North
Dakota already ban health insurance companies from covering abortion
except by optional rider. If an insurer offers abortion in cases
other than life endangerment, rape or incest, then it must separate
the cost of such coverage and charge a separate premium for such
•Paying for care
I don't need means higher premiums. Thisisn't
a myth as much as a misunderstanding of how the law works. In order
to make insurance affordable for all Americans a "single risk pool"
is created. Since the risk is shared by all insurers, premium prices
reflect not only the risk, but all benefits, rights, and protections
offered by the Affordable care Act. The only way to provide
affordable health insurance for the sick, is for the healthy to
share the cost: after all you might become sick and need that help
tomorrow, or next year, or in ten years time. This is the way
employer group plans work. However, unlike employer group plans,
marketplace plans for individuals allow a lower premiums for younger
members, while limiting the maximum premium paid by the elderly to
three times the premium for a young person. The only way to offer
specific care to specific people for specific prices, would be to
eliminate the ban on imposing annual and lifetime limits, the ban on
gender and health discrimination, and the ban on denying coverage
and treatment to people with preexisting conditions. As it stands
now many people will pay less than they did before the law due to
the aforementioned bans and subsidies, while many will pay more due
to the way the new system works. Regardless all Americans buying new
plans will have better benefits, rights, and protections on